Background: The VA is tasked with providing specialty care services for ~4 million Veterans annually, and specialty care for obstructive sleep apnea (OSA) provides representative challenges and opportunities to improve access to high-quality care. Almost 50% of Veterans are at high risk for OSA, and care to diagnose and treat OSA can improve quality of life and health outcomes. However, the VA has limited capacity to meet demands for OSA care with just over 300 sleep providers nationwide, and these specialists are concentrated in VA medical centers (VAMCs), far from many Veterans. Referrals to community care providers represent one strategy to meet demands for OSA testing, but these community referrals often lead to delayed and more expensive care than necessary. As an alternative, a virtual approach incorporating E-consultation is used at some VA medical centers to improve the reach and capacity of VA sleep providers. However, the effect of virtual consults on important OSA treatment outcomes is unknown. Furthermore, virtual consults themselves do not address the need for on-site services to train Veterans to use necessary testing and treatment equipment. The nominee plans to address these gaps by refining and testing the feasibility and effectiveness of a virtual consult pathway to provide care to Veterans at rural community based outpatient clinics (CBOCs). His intervention will consist of virtual sleep consults supplemented with embedded respiratory therapists to provide services on-site. The nominee also seeks to understand the cost implications of current approaches to meet Veterans' OSA testing needs, and estimate the budget impact of expanding VA based services. Significance/Impact: Dr. Donovan's research addresses three key VA priorities. (1) Provide greater choice for Veterans: The virtual consult intervention will allow more Veterans to choose VA services rather than rely solely on community care. (2) Focus resources more efficiently: His research pilots an intervention intended to provide more affordable and effective OSA care. (3) Improve timeliness of care: The proposed work seeks to improve access to proximal and timely sleep care for Veterans otherwise referred to the community. Innovation: The virtual care intervention challenges the current medical center focused model of VA specialty care. Dr. Donovan's intervention would redeploy respiratory therapists to provide necessary on-site services for OSA care at CBOCs, obtain specialist input through E-consultations, and use VA ECHO telementorship sessions to support the ongoing engagement and training of remote providers. In addition, Dr. Donovan plans novel budget impact analyses to inform where it is more advantageous for the VA to expand existing sleep services or purchase them from the community (i.e ?make vs. buy?). Specific Aims: (1) Assess Veteran and provider perspectives regarding initial OSA care. (2) Test the feasibility and acceptability of a virtual consult pathway for initial OSA care. (3) Assess the nationwide impact of community care referrals for OSA testing on diagnostic costs, timeliness to care, and treatment adherence. Methodology: In Aim 1, Dr. Donovan will conduct qualitative interviews among 20 Veterans referred to sleep care in the community, and 12 VA care providers. In Aim 2, Dr. Donovan will enroll 70 Veterans in a pilot randomized trial of a virtual consult pathway versus community care referrals, and this pilot will address the feasibility of procedures and data collection necessary for a definitive trial. In Aim 3, Dr. Donovan will assess nationwide costs of OSA care for VA relative to Community Care. Dr. Donovan will use these costs to perform budget impact analyses of expanding VA-based care relative to community care referrals. Next Steps/Implementation: The research and training activities in this award will enable the nominee to conduct a type I hybrid effectiveness-implementation trial. This multi-site trial will test the effectiveness of virtual sleep care relative to community care referrals to improve patient reported OSA symptoms, experience, and costs, while simultaneously engaging in a process evaluation to identify barriers to implementation.